ANTICHOLINERGIC vs. CHOLINERGIC EFFECTS

ANTICHOLINERGICCHOLINERGIC

Mucus Bronchodilation Dry mouth Dry eyes Urinary retention Dry skin Constipation Shut down GI Prevents V when trying to intubate Bronchorrhea (large amounts of mucus in airway) Bronchoconstriction Salivation Lacrimating Urination Diaphoresis/Diarrhea GI Upset Emesis

ACID BASE GASES

A. ABG Interpretationa. Rule of the Bsi. If the pH and the BICARB (HCO3) ii. Are BOTH in the same direction,iii. Then it is METABOLICb. pH = acidosisc. pH= alkalineB. Valuesa. Normal pH = 7.35 7.45b. Normal Bicarb= 22-26c. PaO2= 80-100 mmHgd. PaCO2= 35-45 mmHge. SaO2= 95-100%C. Signs & Symptoms of Acid-Base Imbalancea. As the pH goes, so goes the patient except for Potassium (bc it will try to compensate)pH UP K [ALKALOSIS] pH DOWN K [ACIDOSIS]

Tachycardia Tachypnea Diarrhea Tremors Seizure Hyperreflexia Agitated Borborygmi ( bowel sounds) Hypertension Palpitations Tetany Anxiety/Panic Poly

Bradycardia Bradypnea Hypotension lucidity anorexia coma lethargy cardia arrest suppressed, decreased, falling

D. Causes of Acid-Base Imbalancea. First ask, Is it Lung?i. If YES- then it is Respiratoryb. Then ask yourself:i. Are they Overventilating or Underventilating?1. If Overventilating pick Alkalosis2. If Underventilating pick Acidosisc. If not lung, then its Metabolici. If the patient has prolonged gastric vomiting or suction, pick Metabolic Alkalosisii. For everything else that isnt lung, pick Metabolic Acidosis1. Also, if you dont know what to pick choose Metabolic Acidosis

VENTILATOR ALARMS

1. High Pressure Alarms are triggered by resistance to air flow and can be caused by obstructions of three types:a. Kinked Tubei. NRS ACTION: Unkink itb. Water in tubing (caused by condensation)i. NRS ACTION: Empty it/Remove H2Oc. Mucus in airwayi. NRS ACTION: Turn, C&DB; only use suction if C&DB fails, as a last resort

2. Low Pressure Alarms are triggered by resistance to air flow and can be caused by disconnections of the:a. Tubingi. NRS ACTION: Pay attention to where tubing is(contamination)ii. If on floor, change outiii. If on chest, clean with alcohol then put back on3. Respiratory Alkalosis (Overventilation) means ventilator settings may be too HIGH.4. Respiratory Acidosis (Underventilation) means ventilator settings may be too LOW.5. To Wean To gradually and incrementally decrease with the goal of ridding all together

ALCOHOLISMNote: Remember in a psych question if you are asked to prioritize DO NOT forget Maslow! Use the following priorities:1. Physiological2. Safety3. Comfort4. Psychological5. Social6. Spiritual

Also, ALL PSYCH PATIENTS START AS MED SURG PATIENTSRULE OUT ALL FEASIBLE MED ANSWERS BEFORE PICKING PSYCH ANSWERS

1. Psychodynamics of Alcoholisma. The #1 psychological problem in abuse is DENIAL.i. Definition:1. Refusal to accept the reality of their problem. ii. Treatment:1. Confront it by pointing out to the person the difference between what they say and what they do. 2. In contrast, support the denial of loss and grief (BC the use of denial is serving a functioning person)b. DEPENDENCY/CODEPENDENCYi. Dependency: When the abuser gets the significant other to do things for them or make decisions for them.ii. Codependency: When the significant other derives positive self-esteem from doing other things for or making decisions for the abuser. iii. Treatment:1. Set boundary (limits) and enforce them. Agree in advance on what requests are allowed then enforce the agreement2. Work on the self-esteem of the codependent person. c. MANIPULATIONi. Definition: When the abuser gets the significant other to do things for him/her that are not in the best interest of the Significant Other. The nature of the act is dangerous or harmful to the significant otherii. Treatment:1. Set limits and enforce2. Its easier to treat than dependency/codependency because nobody likes to be manipulated2. Wernickes (Korsakoffs) Syndromea. Psychosis induced by Vitamin B1 (Thiamine) deficiency.b. Primary symptom: amnesia with confabulation (making up stories to fill in memory lossbelieve as true)c. Characteristics:i. Preventable1. By giving B1 vitaminsii. Arrestable1. Can stop from getting worse- not imply betteriii. Irreversible1. Dementia symptoms dont get betteronly worse3. Antabuse/Reviaa. Disulfiram (drugs used for alcoholismb. Aversion Therapyc. Onset and duration of effectiveness: 2 weeksi. Take drugs 2 weeks and builds up in blood to a level that when drinking alch will become horribly sick; if off for two weeks, will be able to drink without sickness againd. Patient teaching: Avoid ALL forms of alcohol to avoid nausea, vomiting, and possibly death, including:i. Mouthwash, aftershave, perfumes/cologne, insect repellant, vinigarettes (salad dressings), vanilla extract, elixirs (contains alch-OTC med), alcohol prep pad, alch sanitizers

OVERDOSE VS. WITHDRAWALFirst ask yourself, is the drug an upper or a downer?

UPPERS DOWNERS

Names: Caffeine Cocaine PCP/LSD (Psychedelic hallucinogens) Methamphetamines-speed ADHD- adderrall/Ritalin Bath Salts (Cath-Kath)Names: Everything else

Signs/Symptoms: Tachycardia Hypertension Diarrhea Agitation Tremors Clonus Belligerence Seizures Exaggerated, shrill, high pitched cry Difficult to console

Signs/Symptoms: Bradycardia Hypotension Constipation Constricted pupils Flaccidity Respiratory arrest Decreased core body temp

Then ask yourself, Are they talking about overdose or withdrawal?Overdose/IntoxicationWithdrawal

I have too muchI dont have enough..

Too much upper: Everything is UP

Too little upper: Everything is DOWN

Too much downer Everything is DOWN Too little downer: Everything is UP

Drug Addiction in the Newborn

Always assume intoxication (first 24 hours after birth), then after this time, assume withdrawal

Alcohol Withdrawal Syndrome vs. Delirium Tremens

1. Differences:a. Every alcoholic goes through alcohol withdrawal syndrome (AWS) (after 24 hours)b. Only a minority get delirium tremors (DT)c. AWS is not life threatening. DTs can kill you.AWSDTsBOTH

Semi-private-anywherePrivate-near nurses stationAnti-hypertensives

Regular dietClear liquids or NPOTranquilizer

Up Ad Lib (no activity restriction)Restricted bedrest (no bathroom privileges)B1 multi-vitamin (to prevent dementia)

Do not restrainShould be restrained (2 pt leather restraints)2 extremity restrictedarm on one side and leg on one, one upper extremity and one opposite lower extremity

d. Patients with AWS are not dangerous to themselves or others. Patients with DTs are dangerous to self and others.

AMINOGLYCOSIDES

1. Think A mean old mycin2. Powerful antibioticsto treat severe, life-threatening, resistant infections3. All aminoglycosides end in mycin, but not all drugs that end in mycin are aminoglycosides. For example..a. Azithromycin, clarithromycin, erythromycin thromycin NOT4. Examples of aminoglycosides: Streptomycin, Cleomycin, Tobramycin, Gentamicin, Vancomycin, Clindamycin5. Toxic Effects: a. The most famous feature of the worlds most famous mouse (ears)i. Toxic effect: ototoxicityii. Must monitor hearing, balance, tinnitusb. The human ear is shaped like a kidneyi. Toxic effect: nephrotoxicityii. Monitor: creatinine1. Best indicator of kidney function2. 0.6-1.2 mg/dLc. The number 8 drawn inside the ear reminds you of:i. Cranial nerve 8 (Drug toxic to)ii. Frequency of administration: Every 8 hours6. Route of Administrationa. Give IM or IVb. Do not give PO (not absorbed) except in these two cases:i. Hepatic encephalopathy1. Also called Liver Coma, Ammonia-Induced Encephalopathy2. When want a sterile bowel3. Due to a high ammonia levelii. Pre-op Bowel surgery1. REMEMBER this military sound off:a. NEOmycinb. KANmycinc. WHO CAN STERILIZE MY BOWEL? NEO KANd. ^ PO, 2 bowel sterilizers7. Trough and Peak Levelsa. Reason for drawing TAP levels: narrow therapeutic rangeb. Time table:ROUTETROUGH (lowest)PEAK (highest)

Sublingual30 min before next dose5-10 mins after drug dissolve

IV30 min before next dose15-30 min after drug finished

IM30 min before next dose30-60 min after drug given

SQ30 min before next doseSee diabetes lecture

PO30 min before next doseForget about it.

BIOTERRORISM

1. Categories of Biological Agentsa. Category A (Most serious)i. Small poxii. Tularemiaiii. Anthraxiv. Plaguev. Hemorrhagic fever [Ebola]vi. Botolismb. Category Bi. All others. A long list.c. Category Ci. Hanta virusii. Nipeh virus2. Category A Biological Agentsa. Smallpoxi. Inhaled transmission/on Airborne Precautionsii. Dies from septicemia. Blood infection. *only class A that dies from this.iii. Rash starts around mouth first (early ID & isolation is crucial to contain)b. Tularemiai. Inhaledii. Chest symptoms (coughing, chest pain, sputum)iii. Dies from respiratory failureiv. Treat with Streptomycin (watch hearing and creatinine)c. Anthraxi. Spread by inhalationii. Looks like flu (chest symptoms and achy muscles)iii. Dies from respiratory failureiv. Treat with Cipro, PCN, and streptoycind. Plaguei. Spread by inhalationii. Has the 3 Hs:1. Hemoptysis (coughing up blood)2. Hematemesis (vomiting blood)3. Hematochezia (bloody diarrhea)iii. Dies from respiratory failure and DICiv. Treat with Doxycycline and Mycinsv. No longer communicable after 24 hours of treatmente. Hemorrhagic Fever [Ebola]i. 21 day time frameii. Primary symptoms are petechair and ecchymosisiii. High % fataliv. Die of DICf. Botolismi. Ingested (drink/eat)ii. Has 3 major symptoms:1. Descending paralysis (starts at head-goes down to diaphragm)2. Fever3. But is alertiii. Dies from respiratory failure3. Chemical Agentsa. Mustard Gas Blisters (Vesicant, eventually cover airway)b. Cyanide Respiratory arrest. Treat with Sodium Thiosulfate IVc. Phosgine chloride Chokingd. Sarin Nerve agent. i. Symptoms (Cholinergic Effects)1. Bronchorrhea2. Bronchoconstriction3. Salivation4. Lacrimating5. Urination6. Diaphoresis/diarrhea7. GI upset8. Emesis4. All chemical agents require only soap and water cleansing except for Sarin, which requires a bleacha. Nursing Actions: Bioterrorism- Isolation, Antibioticsb. Chemical: Decontaminationi. Send all suspected cases to decontamination centerii. Remove all clothingiii. Chemical hazard double bagiv. Incineratedv. Shower in soap and water (bleach- sarin)vi. Discharged in government clothes

CALCIUM CHANNEL BLOCKERS

Note: They are like Valium for your heart

1. Calcium Channel Blockers: Negative [ ino, chrono, dromo ]Dig is only drug that mixes + & - effects; other 99% either have + or -ACTIONDEFINITIONPOSITIVENEGATIVE

InotropicStrength of heartbeatStrongWeak

ChronotropicRate of heartbeatFastSlow

DromotropicConductivityExcitableBlocks/Slows conduction

2. What do Calcium Channel Blockers treat? (Indications)a. Antihypertensives (BP way UP-relaxes blood vessels)b. Antianginal (relaxes- reduces O2 demand)c. Anti Atrial Arrthymia (does not tx ventricular arrthymias)3. Side Effects():a. Headacheb. Hypotensionc. Bradycardia4. Names of Calcium Channel Blockersa. soptin (Verapeunil)b. zemc. dipine5. Nursing Actions: before administrating BP systolic lower than 100..if < 100 hold and call Dr

CARDIAC ARRYTHMIAS1. Terminologya. QRS depolarization always refer to ventricular (not atrial, junctional, or nodal)b. P wave refers to atrial2. Six rhythms tested on NCLEXa. Asystolei. A lack of QRS depolarizations (a straight line)b. Atrial flutteri. Rapid P-wave depolarizations in a saw-tooth (flutter)c. Atrial fibrillationi. Chaotic P-wave depolarizations (lacks any discernable pattern)d. Ventricular fibrillationi. Chaotic QRS depolarizationse. Ventricular tachycardiai. Wide, bizarre QRSsii. Tachy is always discernable repeating patternf. Premature ventricular contractions (PVC)i. Periodic wide, bizarre QRSsii. Generally low to moderate priority. unless everyone else has a normal rhythmiii. Be concerned, if:1. More than 6 per minute2. 6 in a row3. PVC falls of T-wave of previous beat3. Lethal arrhythmiasa. Asystoleb. V-fib4. Potentially life threatening arrhythmia: V-tacha. Pulseless v-tach; same as asystole and v. fib and would depend on how long downb. After 8 mins consider dead5. Treatmenta. PVCsi. Lidocaine (Ventricular, lasts longer), Amiodoroneb. V Tachi. Lidocainec. Supraventricular arrhythmiasi. Adenosine (push fast IV push; usually 8s or faster)ii. Beta-Blockers (-lol)iii. Calcium Channel Blockersiv. Digoxin (Digitalis) Lanocind. V-Fibi. Best treatment electricallyii. Shock = 200 Defibrillatee. Asystolei. Epinephrineii. Atropineiii. S/E anticholinergics

CHEST TUBES

The purpose for chest tubes is to re-establish negative pressure in the pleural space1. In a pneumothorax, the best tube removes air2. In a hemothorax, the chest tube removes blood3. In a pnemohemothorax, the chest tube removes air and blood

Location of chest tubes:1. Apicals (HIGH) for Aira. Label A- up high2. Basilar (LOW) for Blooda. Label B- placed at base; bottom of lung

Examples1. How many chest tubes (and where) for unilateral pneumohemothorax? a. 2; apical and basilar all on same side2. How many chest tubes (and where) for bilateral pneumothorax?a. 2; apical right and left3. How many chest tubes (and where) for post-op chest surgery?a. 2; apical and basilar unilateralb. Exception: If surgery total pneymonectomy then no chest tube bc no pleural spacec. Always assume chest trauma and surgery is unilateral

Problem Solving

1. What do you do if you kick over the collection bottle?a. Not a big deal; can just sit it right back up; have take a couple deep breaths2. What do you do if the water seal breaks?a. This is more serious, because it is allowing air in creating a 2 wayb. First: Clamp chest tube (Better no way than 2 way for brief period of time) **in routine care never clamp chest tube!!c. Best: Submergei. Cut tube away (down) by device; submerge under water preferably sterile-then unclamp3. What do you do if the chest tube comes out?a. First: cover hole with gloved hand; Vaseline gauze dressing; 4 sided sterile dressing; tapeb. Best: Vaseline gauze4. Bubblinga. Ask yourself two questions:i. WHEN is it bubblingii. WHERE is it bubbling

5. Rules for clamping the tube:a. Never clamp for longer than 15 seconds without a Dr.s orderb. Use rubber tipped double clamp

CONGENITAL HEART DEFECTS

Every congenital heart defect is either TROUBLE or NO TROUBLE

T R o u B L eR-L Blood shuntsB CyanoticT All CHDs beginning with T are troubleException Left ventricular hyperplasic syndromeExamples of TroubleExamples of No Trouble

Tricuspid Tricuspid arterioles Tetralogy of Fallot

Ventricular septal defect Patent foramen ovale Patent ductus arterioles Pulomary

All CHD kids have two things whether trouble or not:1. Murmur2. All get echocardiogram done (@ least 1)

Four defects present in Tetralogy of Fallot:1. VarieD Ventricular Defect2. PictureS Pulmonic Stenosis3. Of A Overriding Aorta4. RancH Right Hypertrophy

CRUTCHES, CANES, & WALKERS

1. How to measure: 2-3 finger widths below anterior anxillary fold to a point lateral to and slightly in front of foot2. When the handgrip is properly placed, the angle of elbow flexion will be 30 degrees3. Types of gaits:a. 2-Point Gaiti. Step One: Move one crutch and opposite foot togetherii. Step Two: Move other crutch and other foot togetheriii. Remember: 2 points together for a 2 point gaitiv. Examples: one knee replacementb. 3-Point Gaiti. Step One: Move two crutches and bad leg togetherii. Step Two: move good foot by selfiii. Remember: 3 point is called 3 point because three points touch down at onceiv. Examples: Stairsc. 4-Point Gaiti. Step One: One crutchii. Step Two: Opposite footiii. Step Three: Other Crutchiv. Step Four: Other foodv. Examples: total both knee right after surgeryd. Swing-through: for two braced extremitiesi. Examples: arthritis braced legs4. When to use each gaita. Use the even numbered gaits (2&4 point) when weakness is evenly distributed (bilateral). Two point for mild problem; four-point for severe problemb. Use the odd numbered gait (3 point) when one leg is odd (unilateral problem)5. Stairs: which foot leads when going up and down stairs on crutches?a. Remember: UP with the good; DOWN with the badb. The crutches always move with the bad leg6. Canea. Hold can on the strong (unaffected) sideb. Advance cane with the weak side for a wide base of support7. Walkersa. Pick it up, set it down, walk to itb. Tie belongings to side of walker, not frontc. Getting out of chair to walker- always push, never pull (same for cane, crutches)

DELUSIONS, HALLUCINATIONS, & ILLUSIONS1. Psychotic vs Non-Psychotica. A non-psychotic person has insight & is reality basedb. A psychotic person has NO insight and is NOT reality based2. Delusionsa. Definition: a delusion is a false, fixed belief or idea or thought. There is no sensory component.b. Three types of delusions:i. Paranoid or Persecutory: false, fixed belief that people are out to harm you.ii. Grandiose: False, fixed belief that you are superioriii. Somatic: False, fixed belief about parts of your body3. Hallucinationsa. Definition: a hallucination is a false, fixed sensory experienceb. Five types of hallucinations:i. Auditory (most common* hearing)ii. Visualiii. Tactileiv. Olfactoryv. Gustatory4. Illusionsa. Definition: An illusion is a misinterpretation of reality. It is a sensory experience.b. Differentiation between illusions & hallucinations: with illusions there is a referent in reality5. When dealing with a patient experiencing delusions, hallucinations or illusions, first ask yourself, What is their problem?a. Functional Psychosisb. Psychosis of Dementiac. Psychotic Delirium6. Functional Psychosisa. These are:i. Schizophreniaii. Schizoaffective Disorderiii. Major Depressioniv. Maniab. Patient has the potential to learn realityc. Four steps:i. Acknowledge how they feelii. Present realityiii. Set a limitiv. Enforce the limit7. Psychosis of dementiaa. These are:i. Alzheimersii. Senilityiii. Organic Brain Syndromeiv. Post Strokev. Wernickesb. This patient has a destructive problem and cannot learn reality.c. Two steps:i. Acknowledge their feelingsii. Redirect8. Psychotic deliriuma. Description: Episodic, temporary, sudden onset, dramatic, loss of reality, secondary to a chemical imbalanceb. Two steps:i. Acknowledge their feelingii. Reassure (it will get better, I will keep them safe)9. Loosening of associationa. Flight of Ideas: stringing phrases togetherb. Word salad: string words togetherc. Neologisms: making up new words10. Narrowed self-concept: a. when a PSYCHOTIC refuses to:i. Leave the room and refuses to change their clothingii. Action- do not make them! Tell them they can wait until they are ready11. Ideas of referencea. When you think everyone is talking about you

DIABETES MELLITUS

1. Definition: DM is a error of glucose metabolisma. (vs Diabetes Insipidus polyuria, polydipsia leading to dehydration)2. Types:a. Type Ii. Insulin dependentii. Juvenile Onsetiii. Ketosis prone (tend to make ketones)b. Type IIi. Non all the aboveii. Non insulin dependentiii. Non juvenile onsetiv. Non ketosis prone3. Signs and Symptomsa. Polyuriab. Polydipsiac. Polyphagia4. Treatmenta. Type Ii. Diet (3)ii. Insulin (1)iii. Exercise(2)b. Type IIi. Diet (1)ii. Oral hypoglycemics (3)iii. Activity (2)c. Diet (type II)i. Calorie restrictionii. Need to eat 6x a dayd. Insulin acts to lower blood sugari. Types of insulin

Type of InsulinOnsetPeakDuration

REGULAR (clear, short acting, rapid; IV)1 hour2 hours4 hours

NPH (cloudy, intermediate acting)6 hours8-10 hours12 hours

HUMALOG (Insulin Lispro) (Worlds fastest acting; give with meals)15 minutes30 minutes3 hours

Lantus (Glargine) (long acting insulin)Slow absorptionNo peak, therefore no risk of hypoglycemia12-24 hours

ii. Check expiration date1. After open new expiration date 20-30 days after openingiii. Refrigeration: optional for opened; necessary for unopenede. Exercise Potentiates (decreases) insulin:i. If more exercise, need decrease insulinii. If less exercise, need increase insulinf. Sick daysi. Take insulin (even if not eating!)ii. Take sips of H20 to prevent dehydrationiii. Stay as active as possible5. Complications of DMa. Low Blood Sugar in Type I DM (=insulin shock) [Hypoglycemia]i. Causes:1. Not enough food2. Too much exercise3. Too much insulinii. Danger:1. Permanent brain damageiii. Signs and Symptoms1. Cerebral impairment & vasomotor collapse (blood vessel wall muscles dont have enough E to maintain tone) slurred speech, staggered gait, abnormal reaction time, uncontrolled emotions, lowered BP, increased pulse, skin pale, cold, clammy, inattentive to social boundariesiv. Treatment1. Administer rapidly metabolizable Carbohydrates (sugar)2. Ideal combination: food with sugar and protein (& maybe starch)3. If unconsciousness: Nothing! Glucagon IM, Dextrose IV, never anything in mouth!b. High Blood Sugar in Type I DM- DKA Diabetic Coma [Hyperglycemia]i. Causes:1. Too much food2. Not enough insulin3. Not enough exercise4. #1 cause is acute viral upper respiratory infection within the last week or twoii. Signs and Symptoms1. Dehydration (appear dry, hot, flush, HA, pulse weak, thready, increase in temp)2. Ketones (in urine & blood); increase in K+; Kussmaul respirations3. Acidodic; acetone (fruity) breath; anorexia with nauseaiii. Treatment1. IV with regular insulin @ 200/hr at high flow ratec. Low Blood Sugar in Type II DM (Hypoglycemia)i. Treatment is the same as for low BGM in Type I Diabetesd. High Blood Sugar in Type II DM (Hyperglycemia)i. Called HHNK (or HHNC):1. Hyperosmolar, hyperglycemic, non-ketotic comaii. This is dehydrationiii. Signs & symptoms are like S&S of dehydration1. Including: increased tempiv. Treatment: rehydrate (glucose will usually turn to normal on own)e. Long term complications are related to two problems:i. Problems with tissue perfusionii. Peripheral neuropathy (nerve damage)f. Which lab test is the best indicator of LT BGM control (compliance/effectiveness) ? Hemoglobin A1Ci. HA1C for dx >6.5 DM/pre DMii. Monitoring tx >7.0 out of control

DRUG TOXICITIES

DRUGTHERAPEUTIC LEVELTOXIC LEVEL

Lithium (antimania)0.6-1.2> 2.0

Lanoxin (uses #1 CHD #2 atrial arrhythmias) 1-2>2

Aminophylline (airway antispasmodic)10-20>20

Dilantin (seizures)10-20>20

Bilirubin (not a drug)Elevated hyperemibilirubin 10-20Toxic >20Kernicterus Bilirubin >20; crosses BBB in CSF- invaded brain causes encephalitis meningitisOpisthotonos Position of extension seen with kernicterus Arching d/t bili irritation in brain Place this child on his/her side

Total bilirubin: 0-1.0 mg/dl Direct (conjugated) bilirubin: 0-0.3 mg/dL Indirect (unconjugated) bilirubin: 0-0.3 mg/dL

DUMPING SYNDROME VERSUS HIATAL HERNIAHIATAL HERNIA (2 chambered stomach)DUMPING SYNDROME

DEFINITION Regurgitation of acid into esophagus, because upper stomach herniates upward through the diaphragm Gastric contents move in the wrong direction (UP instead of DOWN) direction at the correct rate Post op gastric surgery complication in which gastric contents dump too quickly into the duodenum

Gastric contents move in the correct (DOWN) direction at the wrong (too fast) rate

SIGNS & SYMPTOMSUpper GI S/S: Indigestion Heart burn GERD Chest painLower GI S/S Acute lower abdominal distress: diarrhea, cramping, gas, abdominal pain, cramping, guarding, splinting, rigidity, distension Drunk (look), all blood going to gut not brain ( cerebrally impaired; confused Shock: blood in parasympathetic system; pale, cold, clammy, decreased BP, rapid pulse D&S hypoglycemis

Treatment1. HOB during & 1 hour after meals2. Amount of fluids with meals3. Carbohydrate content of meals1. Raise HOB (High Fowlers)2. High Fluids3. High Carbs (Decrease Protein)1. Low HOB2. Low/Restricted fluids- in between meals3. Low Carbs (Increase Protein)

ELECTROLYTES

KALEMIAS do the same the prefix except for heart rate and urine output

HYPERKALEMIA HR UOHYPOKALEMIA HR UO

CALCEMIAS do the opposite the prefix. No exceptions. [& anything to BP]

HYPERCALCEMIA HYPOCALCEMIA

Two signs of neuromuscular irritability associated with low calcium:1. Chovosteks sign Tap cheek spasm

2. Trousseaus sign Put on BP cuff and arm goes into carpal spasm( arm looks like swan neck)

MAGNESEMIAS do the opposite the prefixNote: In a tie, never pick Mg. If symptom involves nerve or skeletal muscle, pick Calcium. For any other symptom, pick Potassium

HYPERMAGNESEMIA HYPOMAGNESEMIA

NATREMIAS

HYPERNATREMIA E dehydration HYPONATREMIAO overload

Poor skin turgor Dark urine Hot flushed skin Increase urine specific gravity Weak, thready pulse

Increased weight edema

The earliest sign of any electrolyte disorder is numbness (paresthesia) & tingling

The universal sign/symptom of electrolyte imbalance is muscle (paresis) weakness

ELECTROLYTE TREATMENT1. Never push Potassium IV [Fatal]2. Not more than 40 mEq of K+ per liter of IV fluid [clarify if over 40]3. Give D5W with regular insulin to decrease K+ [carrier mediated transport]4. Kayexalate [K-exit-late]a. Puts drug in gut, full of sodium; Na picked up by bloodstream; Doesnt need that much + charge, so body exchanges for K, diarrhea)b. B/C is slow do this with D5W + insulin

ENDOCRINE OVERVIEWThyroid

1. Hyperthyroidism (Hyper-Metabolism)i. Signs & Symptoms1. weight tachycardia BP Agitation Restlessness nervousness diarrhea energy bulging eyes warm 104 Fb. Very high V/Sc. Psychotic Delirium *life threatening priority3. Treatmenta. Wait out: either die, come out, give O2 and lower body tempb. Tx focuses on saving the brain until they come out of itc. Lowering body temp:i. Ice packs: on axilla, axilla, groin, groin, back, neckii. Cooling blanketiii. Post-op risks 1st 12 hours airway&hemorrhage **after first 12 ours it is assumed that the patient is stable Post-op risks 12-48 hours for TOTAL: calcium (tetany) Post-op risks 12-48 for SUB-TOTAL: Thyroid storm2. Hypothyroidism (Hypo-Metabolism)a. Signs & Symptomsi. weight cold sluggishslow decreased BPbradycardia hair and nails brittledecreased E

b. Name of disease: mxyedemac. Treatment: thyroid pillsd. Caution: DO NOT sedate these patients! (already )e. Surgical Implication: call anesthesiologist and ask if thyroid pills should be held. Do not do well with anesthesia

Adrenal Cortex Diseases (start with letters A or C)1. Addisons Diseasea. Under secretion (too little) of adrenal cortexb. Signs & Symptoms Hyperpigmented (3 or 4 shades darker than before) Inability to adapt normally to stresssends off limitshock

c. Treatmenti. Give steroids [glucocorticoids and mineralcorticoids]1. Steroids all end in sone2. Cushings Syndromea. Over secretion of adrenal cortexb. Signs & Symptoms [also reflex S/S of steroids]c. Treatment: adrenoectomy

INFECTIOUS DISEASE & TRANSMISSIONN-BASED PRECAUTIONSSelect all that apply

Private RoomEye/Face Shields

MaskSpecial Filter Respirator Masks

GlovesPt wear mask when leaving room

GownDisposable supplies

HandwashingNegative air flow

Contact: For :1. Herpes, 2. anything Staph (MRSA), 3. Enteric (intestinal) [cholera, shigellosis, rotovirus], 4. RSV (Respiratory Synctial Virus)a. [spread droplet; but research found this is best for precautions]

Droplet: For1. ALL Viruses2. ALL Influenzas [DTaP, Pertussis, Mumps]Select all that apply

Private RoomEye/Face Shields

MaskSpecial Filter Respirator Masks

GlovesPt wear mask when leaving room

GownDisposable supplies

HandwashingNegative air flow

Select all that apply

Private RoomEye/Face Shields

Mask most importantSpecial Filter Respirator Masks

GlovesPt wear mask when leaving room

GownDisposable supplies

HandwashingNegative air flow

Airborne:For:1. TB *spread drolet2. Chicken Pox (varicella)3. Measles4. SARS (Severe acute respiratory system)

Select all that apply

Private RoomEye/Face Shields

Mask Special Filter Respirator Masksw/TB only N95

GlovesPt wear mask when leaving room

GownDisposable supplies

HandwashingNegative air flow

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Unless otherwise specified, assume that PPE includes: Gowns, Goggles, Mask, Gloves

The proper place for donning (putting on) PPE is outside of the room

The proper order for donning PPE is:1. Put on gown2. Put on mask3. Put on goggles4. Put on gloves

The proper place for removing (doffing) PPE is inside room

The proper order for removing PPE is:1. Gloves2. Goggles3. Gown4. Mask need to take mask off outside so you dont breathe in contaminated airIn airborne precautions ONLY, the mask is removed outside of the room

HANDWASHING AND GLOVING

HandwashingHandwashing versus ScrubbingHandwashingScrubbing

PositionHands below elbowsElbows below hands

LengthSecondsMinutes

HandlesYes; sink with handlesNo sink with handles

WhenUpon entry or leaving room before and after gloving, when soil handsWhen patient is immunosuppressed for any reason

UseSoap and waterSomething with chloro in it

Use an Alcohol-Based Solution1. On entering or leaving a room2. Before putting on gloves, after taking off gloves3. Cannot after soil hands!!

What about after using the rest room? must use soap and water

Dry from cleanest (hand) to dirtiest (elbow)

Turn water off with new paper towel

Sterile GlovingGlove dominant hand first.Grasp outside of cuff.Touch only the inside of glove surface. Do not roll cuff.Fingers inside of second glove cuff.Keep thumb abducted back.Only touch outside surface of gloveSkin touches inside of gloveOutside of glove only touches outside of gloveRemove glove to glove Skin to skin

INTERDISCIPLINARY CARE

Identifying which patients need interdisciplinary caredifferent than prioritizing who would most benefit from a team working together on their care

Patients who do not need interdisciplinary care: Patients who need or have multiple doctors

Patient who DO need interdisciplinary care:1. Major Criteriaa. Patients with multi-dimensional needsi. For example:1. Physical 2. Psychological3. Social4. Spiritual5. Intellectual needsb. Patients who need rehabilitation2. Minor Criteria [choosing between patients]a. A patient whose current treatment is ineffectiveb. A patient who is preparing for discharge

LAB VALUES

A=ABNORMAL Do NothingB= BE CONCERNED Assess/MonitorC=CRITICAL Do SomethingD = DEADLY DANGEROUS Do Something NOW

Creatinine Best indicator of Kidney Function 0.6-1.2 Elevated = A

INR (International Normalized Ratio) Monitors Coumadin (Warfarin) Therapy [Anticoagulant] Therapeutic 2-3 > 4=C Patient could bleed to death Hold all warfarin Assess for bleeding Prepare to administer Vitamin K Call Physician

Potassium (K+) 3.5-5.3 Low=C [Hypokalemia] Assess the heart (may include EKG which aid can do) Prepare to give K+ Call physician 5.4-5.9 = C [Hyperkalemia] High but still in the 5s Hold K+ Assess heart (may include EKG which aid can do) Prepare Kayexelate and d5W with regular insulin Call physician > 6 = D Cardiac Danger Zone Do steps simultaneously Need help once levels hit 6; if cardiac symptomatic call rapid response team

pH 7.35-7.45 (as pH drops so does the patient) K+ can increase which can stop the heart Low pH in the 6s = D [severe acidosis] Immediately assess vital signs Call dr if v/s bad, also call rapid response team

BUN [Blood Urea Nitrogen] 8-30 Elevated =B Check for dehydration

HgB [Hemoglobin] 12-18 8-11 = B